TREASURE COAST COMMUNITY HEALTH, INC. (772) 257-TCCH (8224)
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1 Welcome to Treasure Coast Community Health s Dental Department! It is a pleasure to welcome you to our dental practice and we want you to know that we appreciate the opportunity to take care of your dental needs. We strive to help all of our patients achieve a healthy dental condition. Your care starts with a thorough exam and x-rays that our dentist deems appropriate to help diagnose your dental health and develop a treatment plan for you. TCCH comprehensive dental program offers patients the following services: dental education, dental hygiene care, limited periodontal care (scaling and root planing), preventative care (i.e., sealants), restoration (fillings), removable partials and dentures, and extractions (surgical and non-surgical) on both adults and children. Please be advised that after any of the following exams new patient, periodic, emergency or consultation that some or all of your recommended dental treatment may not be able to be performed at TCCH should it be considered out of the scope of our practice. This includes, but is not limited to, the patient s desire for procedures or treatments such as: dental implants, root canals, crowns and or fixed bridgework, veneers, orthodontics or treatment requiring IV sedation. Patients of TCCH s Dental Department are required to agree to these Standards of Care: 1. TCCH dental providers will make treatment recommendations based on the best clinical judgment, as to the standard of care perimeters which may include: type of dental hygiene procedures required; extraction(s) of teeth; type of dental materials used for fillings, and or removable partials or dentures and use of certain types of fluorides. This may include a referral to see a dental specialist(s) outside of the TCCH. 2. TCCH dental providers determine the sequence of dental treatments and next appointment(s). Patient desires will be considered where possible. However, you and your dental provider will agree upon a Treatment Plan based on priorities of your dental needs and possible consequences of delaying treatment. 3. A Treatment Plan Coordinator will meet with you to review your treatment plan, answer your questions and to schedule your appointments according to your individual needs. 4. A patient who has not had an exam for 2 years at TCCH s dental center will require a new comprehensive exam before any hygiene or non-emergency treatments. 5. Patients who are walk-ins will be seen in the order as the dental center deems is the most appropriate and not who necessarily arrive first. Emergency patients will be evaluated; x-ray films will be taken as deemed appropriate by the dental provider. No dental procedures can be guaranteed that day. 6. A patient who was seen at a TCCH dental office as an emergency only patient (or has a history of emergency exam visits) will not be considered as a patient for continuity of care. 7. Your dental and medical health is our first priority at TCCH. Many times a medical condition can affect your dental treatments. Therefore, TCCH requires your recent medical records from your primary care physician. If you do not have a primary care physician we would be happy to establish medical care with one of our TCCH Medical Physicians. 8. If a medical clearance is required for treatment at TCCH, it is your responsibility to obtain the medical clearance from your Physician and return to TCCH. TCCH will be unable to see you for your appointment without this paperwork. 9. If you are seeking a dental clearance that is required promptly for a medical procedure, TCCH is unable to guarantee it. You will need to seek dental clearance elsewhere if needed quickly. 10. Dental No Show/Cancellation Policy: Patients who need to cancel their appointment must do so at least 24 hours prior to their appointment or it will be considered a No Show. Patients (Head of household or guarantor) that have more than 2 No Shows within the past 12 months will not get another appointment for 1 year. Sincerely, Kim Platt Dental Manager TREASURE COAST COMMUNITY HEALTH, INC. (772) 257-TCCH (8224) FELLSMERE SOUTH VERO VERO County Road TH St SW (Oslo Road) st Avenue Fellsmere, FL Vero Beach, FL Vero Beach, FL 32960
2 TREATMENT/PAYMENT AUTHORIZATION FOR TREASURE COAST COMMUNITY HEALTH CENTERS, INC (TCCH) **Please initial next to each line to show that you have read and consent to each statement 1. I give consent and request TCCH to provide me and/or my family with health care**. I acknowledge my responsibility to pay for that care according to the fees established. I have informed TCCH of all insurance coverage. I understand that I am responsible for all charges and fees for my care, except any that are covered by insurance accepted by TCCH. I understand that payment, including co-insurance, co-pays and self-pay/sliding fee payments, is due at the time of service. 2. HEALTH CARE RELEASE I give consent for release of routine medical record information for the purposes of reimbursement, arranging referrals or other health care. I also allow TCCH to release immunizations records to any school or day care. 3. I give permission for my Protected Health Information (PHI) to be disclosed for the purpose of coordinating health care needs, communicating results, and care decisions to the friends and/or family members listed below (Initial if applicable) Name Relationship Contact Number 4. I give permission for the individuals listed below to accompany my minor child (Child s Name) to TCCH. This will allow TCCH to treat the child, discuss the minor s care and PHI, such as treatment plans, appointments, etc. (Initial if applicable) Name Relationship to Patient Contact Number 5. CARE COORDINATION I give consent for coordination of my health care with home and community-based providers of clinical services to also include the chronic care management program. 6. ACCESS I give my consent to access my history from other places (e.g. Pharmacies, Lab Vendors, Accountable Care Organizations), electronically for the purpose of my health care. 7. PATIENT PORTAL I have the opportunity to gain 24 hour access to the Patient Portal. I will keep my sign-on and password safe and access only the accounts I have the right to look at. 8. TEXT/ I give my consent to receive appointment reminders and other healthcare communications/information from TCCH 9. I HAVE BEEN OFFERED AND/OR RECEIVED THE NOTICE OF PRIVACY PRACTICE THIS CONSENT WILL STAY IN EFFECT FOR TWELVE (12) MONTHS FROM THE DATE SIGNED. You have the right to amend or revoke this consent at any time. Signature of: (Circle One) Patient Parent Guardian Date TCCH Staff Member: Date: **Health Care Medical, Dental and/or Behavioral Health TCCH#1007 v3 2.18
3 Medical History: Patient Name: Date of Birth: CHECK ALL ITEMS THAT APPLY TO YOUR HISTORY ADHD/ADD Syncope (Fainting) Anxiety Disorder Alzheimer's/Parkinson's Arthritis Artificial Joint Replacements Asthma Bleeding-Excessive Blood Disease Bone Disease Brain Stimulation Device (DBS) Cancer Central Nervous System Disorder Chronic Pain Management Obstructive Lung Disease (COPD) Lung Problems - Other Developmentally Challenged Kidney Dialysis Organ Transplant-Lung, Kidney, Liver, Pancrease, Bone Marrow (Cirlce) Diabetes Type 1 (Insulin) Diabetes Type 2 (Oral Medication) Eating Disorder Emphysema Thyroid, Parathyroid, Adrenal, Pituitary Problems Eye Disorder Injury to: Face, TMJ, or Jaw Stomach/Intestine Disorder Gout Hearing Impaired Heart Pain-Angina Heart Attack (M.I.): Dates: Heart Stent(S): Dates: Heart Disease Heart Infection (Endocarditis) Pacemaker or Defibrillator Heart Surgery: Dates: Artificial Heart Valve (Circle): Tissue or Mechanical Heaptitis A, B, or C: DATE: High Blood Pressure Low Blood Pressure HIV/AIDS: DATE: Immune System Disorder: DATE: Kidney, Liver, or Pancreatic Disease Lupus Mental Disorder Multiple Myeloma Osteoporosis Cebrebal Palsy Autism Post Traumatic Stress Disorder Radiation to Head, Jaws, or Neck Severe Nightmares Sleep Apnea (Snoring) Seizure Disorder Sexually Transmitted Disease Substance Abuse: Alcohol, Drugs, Other Surgery - Other Stroke Sinus Problems Speech Problems TMJ Problems Thrombo Embolism Tobacco Use Tumors Ulcers Vascular Surgery FEMALES: Pregnant Now Nursing Now Trying to get Pregnant Taking Fertility Drugs Practicing Birth Control PAGE 1 - TURN OVER
4 NOW TAKING MEDICATION FOR ANY OF THE FOLLOWING CONDITIONS (CHECK & CIRCLE): ADHD/ADD Depression Allergies Sedatives or Sleep Aids Adrenal, Thyroid, Parathyroid, or Pituitary Gland Problem Fertility Birth Control Cholesterol Management Pain-Codeine, Percocet, Tramadol, Morphine, Demerol, or Pain Patch Anti Inflammatory - Prednisone, Cortisone Osteoporosis Chronic Pain Management Pain - Ibupropehn, Motrin, Celebrex Diabetes Type 1 Cancer - Radiation Treatment Diabetes Type 2 Cancer - Medication Ulcers, Stomach or Intenstinal Problems Cancer Involvement of Bones Hepatitis Blood Thinners - Coumadin, Pradaxa, Heparin HIV/AIDS Blood Pressure Regulation Hormone - Estrogen Anti Platelet/Clotting - Plavix, Aspirin Non Prescription Street Drugs Aspirin 325mg Immune Suppresive Drugs Aspirin 81mg Kidney, Urinary, Prostate Problems Alzheimer's or Parkinson's Multiple Sclerosis Anti-Seizure Multiple Myeloma Anxiety Plasma Products or Blood Factors Bone Problems Heart Rhythm Problems Breathing Problems - Oxygen Therapy EVER TAKE ANY OF THE FOLLOWING?(CIRCLE & CHECK) Breathing Problems - Inhalers Heart Problems Actonel, Aredia, Boniva, Fosomax, Zometa (Notrogen Conaining Bisphosponates) Atelvia, Didronel, Reclast, Skelid (Non- Nitrogen Containing Bisphosphonates) HAVE YOU EVER HAD ALLERGIES TO: Any Foods: Barbituates, Sedatives, or Sleeping Pills Local Anesthetics (such as Novacain, Ldiocaine, Mepivicaine, etc.) Other: Penicillin, Amoxicilllin, Ampicillin, Augmentin (Penicillin Family) Erythromycin Narcotics: Hydocodone Tetracycline: Oxycodone Demerol Other Zithromax (Azithromycin) Acetaminophen (Tylenol) Cipro Aspirin Clindamycin Aleve Metals: Codeine Latex (Rubber) Tramadol Keflex (Cephalosporin Family) Sulfa Drugs Ibuprofen - (Motrin, Advil or Generic Ibuprofen) Other Drugs Name of any other antibiotic allergy: Hay Fever/Seasonal Barbituates, Sedatives or Sleeping Pills Other Iodine All of the answers above are true and correct. If I have any changes in my Health or my Medications, I will notify the Doctor at my next appointment without fail. Patient/Guardian Signature: DATE:
5 Treasure Coast Community Health, Inc. Telephone (772) Dental History PATIENT NAME: DATE: Height: Weight: Who is your primary doctor? Are you being treated by a Physician for any reason at present? Are you experiencing pain from your mouth at this time? Ever had swollen or bleeding gums? Ever noticed any loose teeth? Ever had injury to your face, jaws, or teeth? Have you ever had gum (periodontal) treatments? Have you ever had braces to straighten teeth? If yes, for how long? Have your teeth been replaced by a: ( ) fixed bridge; ( ) removable partial; ( ) denture Does your jaw click when you chew or open your mouth? Do you have pain in the ( ) jaws, ( ) ears, ( ) temples, ( ) neck. Is this pain present on awakening? Ever have prolonged bleeding following a tooth extraction? Reasons for past extractions: ( ) decay, ( ) loose teeth, ( ) accident Ever had: ( ) canker sores, ( ) cold sores, ( ) mouth ulcers? If yes, then how often? When was you last full mouth X-Ray series taken? Date: Tell us about your previous dental experiences:
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
Julia A. Hallisy, D.D.S., Inc.
Julia A. Hallisy, D.D.S., Inc. Welcome! Thank you for choosing our office for your dental health needs. Please let us know if you need assistance when completing these forms. Name PATIENT INFORMATION Last
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
Welcome to Dr. Halliday s Office
Dentist Medical Dr. Welcome to Dr. Halliday s Office Patient information: Today s Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Home Tel.( ) Cell.( ) Have you
Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
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Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
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Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
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Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
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KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
NEW Adult Patient Information
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Patient Medical and Dental History Personal Information. Name Date
Patient Medical and Dental History Personal Information Name Date (Last) (First) (Middle) Address County City State Zip Day Phone Evening Phone Cell Phone Birth Date Age Occupation Sex M or F Social Security
3. Are you now, or have you been in the past year, under the care of a physician?
Medical History Patient Name Birth Date ID Number 1. Do you have any of the following diseases or problems? Today s Date a. Active Tuberculosis b. Persistent cough greater than 3 weeks in duration c. Cough
Medical and Dental Health History Form Getting to Know You As Our Patient
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APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC
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DENTAL QUESTIONNAIRE
Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
AJ Dental Group, PC Family, Cosmetic & Implant Dentistry
: Patient s Name: Social Security #: How do you wish to be addressed? of Birth: Age: Male Female Minor Single Married Separated Divorced Widowed No answer Residence Street Address: _ City: State: Zip code:
WELCOME Patient Registration Date:
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MEDICAL AND PERSONAL HISTORY
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PERSON RESPONSIBLE FOR PAYMENT Daytime ph Address Driver License State # City State Zip Employed by Or Retired from Address Address
Patient Information Please Print NAME Referred to us by of birth Age Single Married Divorced Widowed Separated Minor (under 18) Full time student Parent/Guardian if minor Address Home ph City State Zip
PATIENT REGISTRATION
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MEDICAL HISTORY. PATIENT NAME Birth Date
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Patient Information. Spouse or Responsible Party Information. Insurance Information
Patient Information Full Name Preferred Name Home Address City, St, Zip Home Phone # E-Mail Address Employed By Work Phone # Occupation Pager/Cell Phone # Male Female Birth Social Security # Married Single
TODAY S DATE FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? SOCIAL SECURITY #
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GENERAL QUESTIONS CONTACT INFORMATION
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline
Patient Registration
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